Health Disparities by Race and Ethnicity: the California Landscape Health Disparities by Race and Ethnicity Executive Summary

CALIFORNIA Health Care Almanac

OCTOBER 2019 Health Disparities by Race and Ethnicity: The California Landscape Health Disparities by Race and Ethnicity Executive Summary

All Californians should have access to the high-quality health care they need to lead a long and healthy CONTENTS life. Achieving this requires reducing disparities in health and the social determinants that affect historically excluded or marginalized groups.* Disparities occur across many dimensions, including race/ Overview...... 3 ethnicity, socioeconomic status, age, place of residence, gender, disability status, and sexual orientation. Access to Care...... 9

As the most racially diverse state in the country, California has a critical stake in addressing health Prevention...... 13 disparities experienced by people of color. Health Disparities by Race and Ethnicity: The California Landscape shows that people of color face barriers to accessing health care, often receive suboptimal Quality...... 17 treatment, and are most likely to experience poor outcomes in the health care system. Chronic Conditions...... 22

KEY FINDINGS Behavioral Health...... 28 • Life expectancy at birth in California was 80.8 years. It was lowest for Blacks, at 75.1 years, and highest for Asians, at 86.3 years, an 11-year gap. Maternal/Childbirth...... 35

• Latinos were more likely to report being in fair/poor health, to have incomes below the federal poverty level, and to be uninsured. About one in five Latinos did not have a usual source of care, and one in six Latinos reported difficulty finding a specialist.

• Blacks had the highest rates of new prostate, colorectal, and lung cancer cases, and the highest death rates for breast, colorectal, lung, and prostate cancer.

• About 1 in 5 multiracial, Black, and white adults reported being told they have depression compared to about 1 in 10 Asian adults.

• Blacks fare worse on maternal/childbirth measures, with higher rates of low-risk, first-birth cesareans, preterm births, low-birthweight births, infant mortality, and maternal mortality.

* Paula Braveman et al., What Is Health Equity? And What Difference Does a Definition Make?, (Robert Wood Johnson Foundation, May 2017), www.rwjf.org.

CALIFORNIA HEALTH CARE FOUNDATION 2 Health Disparities by Race and Ethnicity Population, by Race/Ethnicity Overview California, 1999, 2019, and 2040 California is the most racially diverse state in the country. Over the last

1999 2019 2040 20 years, California’s population has N = 33,418,569 N = 40,295,352 N = 46,804,202 grown more diverse, as Latinos have grown from 32% to 40% of the population and Asians from 12% Latino 32% White 48% White 37% White 33% to 14% while whites have declined Latino 40% Latino 43% from 48% to 37%. Between 2019 and 2040, California’s population is Asian Asian Asian 14% 12% 14% expected to increase by 6.5 million. People of color represent 93%, or 6 Black 7% Black 6% Black 5% million, of the expected increase (not Multiracial 3% Multiracial 3% Native American 1% Native American <1% Native American <1% shown). Pacific Islander <1% Pacific Islander <1%

Note: Segments might not total 100% due to rounding. Source uses Hispanic, American Indian or Alaska Native, and Native Hawaiian or Pacific Islander. Asian includes Pacific Islander in 1999. Multiracial data were not available in 1999. Source: Total Estimated and Projected Population for California: July 1, 2010 to July 1, 2060 in 1-year Increments, California Dept of Finance, January 2018, www.dof.ca.gov.

CALIFORNIA HEALTH CARE FOUNDATION 3 Health Disparities by Race and Ethnicity Population, by Race/Ethnicity and Federal Poverty Level Overview California, 2017 Poverty has been linked to death and disease. According to a recent study, having wealth and a higher income 0–99% 100–199% 200–299% ≥300% provides material benefits such as Latino healthier living conditions and access 28% 27% 14% 31% to health care.* Black Latinos were more likely to have 18% 18% 19% 45% incomes below the federal poverty Multiracial level (FPL) than other races and 16%* 12% 11% 61% represented 66% of all Californians Asian under the FPL in 2017 (not shown). 11% 13% 12% 64% White 7% 11% 11% 71% California 17% 18% 13% 52%

*Statistically unstable. Notes: In 2017, the federal poverty level was $12,060 for a single person and $24,600 for a household of four. American Indian / Alaska Native and Native Hawaiian / Pacific Islander are not * Paula Braveman et al., Wealth Matters for Health Equity, shown because the results were statistically unstable. Source uses African American and Two or More Races. Robert Wood Johnson Foundation, September 2018, Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed May 30, 2019, http://ask.chis.ucla.edu. www.rwjf.org.

CALIFORNIA HEALTH CARE FOUNDATION 4 Health Disparities by Race and Ethnicity Self-Reported Health Status, by Race/Ethnicity Overview California, 2017 Whites and Asians were the most likely to report being in excellent or Poor Fair Good Very Good Excellent very good health while Latinos were the most likely to report being in fair Latino or poor health. 4% 18% 31% 24% 23%

Black 4%* 15% 32% 30% 19%

Asian

3% 9% 26% 37% 25%

White

3% 9% 26% 35% 27%

California

4% 13% 28% 31% 25%

*Statistically unstable Note: Source uses African American. Estimates for American Indian / Alaska Native and Native Hawaiian / Pacific Islander are not shown because the results were statistically unstable. Segments may not total 100% due to rounding. Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed April 12, 2019, http://ask.chis.ucla.edu.

CALIFORNIA HEALTH CARE FOUNDATION 5 Health Disparities by Race and Ethnicity Health Insurance, by Race/Ethnicity Overview California, 2017 Lack of insurance was identified as a Uninsured Medi-Cal Employment- Privately Other Public significant driver of health disparities Based Purchased 4% 4% Latino in the Institute of Medicine report 12% 44% 36% Unequal Treatment: Confronting

Black Racial and Ethnic Disparities in Health 7% 31% 47% 7%* 8%* Care. About one in eight Latinos reported that they did not have White 4% health insurance coverage. Whites 6% 15% 65% 11% and Asians were most likely to report Asian 2%* having health coverage through their 4% 18% 66% 10% employer while Latinos were more

Multiracial 6%* likely to report having Medi-Cal coverage. 5%* 25% 58% 7%

California 4% 9% 29% 51% 8%

*Statistically unstable. Notes: Insurance status is self-reported. Medi-Cal may include those with restricted-scope benefits. Age 0 to 64. Other public includes Medicare only, Medicare & Medicaid and Medicare & Others. Source uses African American and Two or More Races. Estimates for American Indian / Alaska Native and Native Hawaiian / Pacific Islander are not shown because the results were statistically unstable. Segments may not total 100% due to rounding. Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed August 21, 2019, http://ask.chis.ucla.edu.

CALIFORNIA HEALTH CARE FOUNDATION 6 Health Disparities by Race and Ethnicity Life Expectancy, by Race/Ethnicity Overview California, 2017 In 2017, Blacks had the shortest life expectancy at birth compared 86.3 to all other races/ethnicities. Life expectancy for Blacks was eleven 83.2 years shorter than that of Asians and 79.8 80.2 80.8 nearly six years shorter than the state average. 75.1

Black White Native Latino Asian California American

Source: “Life Expectancy by State 2019: Life Expectancy Rates in California in Years,” World Population Review, August 28, 2019, http://worldpopulationreview.com.

CALIFORNIA HEALTH CARE FOUNDATION 7 Health Disparities by Race and Ethnicity Death Rate, by Race/Ethnicity Overview California, 2017 In 2017, Asians had the lowest death AGE-ADJUSTED RATE PER 100,000 POPULATION rate while Blacks had the highest. The death rate for Blacks was more 865.4 than twice as high than the rate for Asians and 40% higher than the state 766.7 CALIFORNIA 688.0 618.7 average.

521.8 402.8

Black Native White Latino Asian / Pacific American Islander

Note: Source uses Hispanic or Latino, Black or African American, American Indian or Alaska Native, and Asian or Pacific Islander. Source: “Underlying Cause of Death 1999-2017,” CDC WONDER Online Database, Centers for Disease Control and Prevention, December 2018, http://wonder.cdc.gov. Data are from the Multiple Cause of Death Files, 1999–2017, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.

CALIFORNIA HEALTH CARE FOUNDATION 8 Health Disparities by Race and Ethnicity Usual Source of Care, by Race/Ethnicity Access to Care California, 2017 About one in five Latinos did not have a usual source of care. Almost Doctor’s office / HMO / Kaiser Emergency room / urgent care Community clinic / government clinic / Some other place / no one place three-quarters of whites reported community hospital No usual source of care that a doctor’s office was their usual 2% <1%* Latino source of care, while more than a third 43% 35% 19% of Latinos reported that their usual Pacific Islander source of care was a community clinic. 46% 40%* 13% Only small percentages of people of all Native American <1%* 56% 34% 7% races/ethnicities used the emergency Asian <1%* <1%* room as a usual source of care. 63% 24% 12% Black 3%* <1%* 64% 24% 8% Multiracial 1%*<1%* 69% 23% 7% White 1% <1%* 74% 16% 8%

* Statistically unstable. Notes: Respondents who have a usual place to go when sick or need health advice. Source uses African American, American-Indian / Alaska Native, Native Hawaiian / Pacific Islander and Two or More Races. Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed May 20, 2019, http://ask.chis.ucla.edu.

CALIFORNIA HEALTH CARE FOUNDATION 9 Health Disparities by Race and Ethnicity Delayed Care Due to Cost or Lack of Insurance, by Race/Ethnicity Access to Care California, 2017 One in 10 Californians reported delaying care. Of those who delayed 58.1% care, almost half cited cost or lack of insurance as the reason. Blacks were less likely than other races/ethnicities 46.8% 47.0% 45.6% to report cost or lack of insurance as 38.0% the reason they delayed care. 34.5%

Black Asian White Latino Multiracial California % WHO DELAYED FOR ANY REASON

12% 6% 12% 10% 14% 10%

Notes: Of those respondents who delayed care, those who delayed due to cost or lack of insurance. Source uses African American. Estimates for American-Indian / Alaska Native and Native Hawaiian / Pacific Islander are not shown because the results were statistically unstable. Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed May 20, 2019, http://ask.chis.ucla.edu.

CALIFORNIA HEALTH CARE FOUNDATION 10 Health Disparities by Race and Ethnicity Difficulty Finding a Doctor, by Race/Ethnicity Access to Care California, 2017 One barrier to care is finding a doctor. All races/ethnicities had more difficulty finding a specialist than a Primary Care Specialist primary care doctor. One in six Latinos 16.6% reported difficulty finding a specialist.

CALIFORNIA 11.5%

10.8%* CALIFORNIA 9.3% 5.7%

6.4% 5.7% 5.6% 6.2%* 3.4%

Asian White Latino Black

*Statistically unstable. Notes: Adults only. Source uses African American. Estimates are not shown for American-Indian / Alaska Native, Native Hawaiian / Pacific Islander, and Two or More Races because the results were statistically unstable. Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed May 20, 2019, http://ask.chis.ucla.edu.

CALIFORNIA HEALTH CARE FOUNDATION 11 Health Disparities by Race and Ethnicity Race/Ethnicity of Physicians and Population Access to Care California, 2015 The racial/ethnic breakdown

Aci Pain Car Phician California Polaion of California physicians is not representative of the state’s diverse Native American (<1%) population. In 2015, Latinos Black Other Black Other represented 38% of the population Latino 6% 3% but only 5% of active patient care 3% 6% 5% physicians. Studies have found that Asian / minority patients in race/ethnic No White Paci c Response 32% Islander White concordant relationships are more 14% 12% N= 39% N=61,196 38.4 million likely to use needed health services, Declined are less likely to postpone or delay to State seeking care, and report greater 14% Asian / Latino Paci c Islander 38% satisfaction and better patient –

28% * provider communication.

Notes: Data include active MDs, except residents and fellows, who practice in California providing at least 20 hours of patient care per week. Other includes American Indian, * Ana H. Traylor et al., “The Predictors of Patient-Physician Native American, Alaskan Native, Native Hawaiian, those of two or more races, and those of unknown race/ethnicity. Source uses African American and American Indian / Alaska Race and Ethnic Concordance: A Medical Facility Fixed- Native. Segments may not total 100% due to rounding. Effects Approach,” Health Services Research 45, no. 3 (June Sources: Survey of Licensees (private tabulation), Medical Board of California, 2015; and 2015 American Community Survey, US Census Bureau. 2010): 792–805, doi:10.1111/j.1475-6773.2010.01086.x.

CALIFORNIA HEALTH CARE FOUNDATION 12 Health Disparities by Race and Ethnicity Routine Checkup, by Race/Ethnicity Prevention California, 2017 About three in four adults reported having a routine checkup in the past 12 months. Blacks were more likely CALIFORNIA 74.0% 81.4% to report having a routine checkup 73.3% 76.6% 70.1% 71.7% within the past year than other racial/ ethnic groups.

Latino Multiracial Asian White Black

Notes: Adults only. Source uses African American and Two or More Races. Estimates are not shown for American Indian / Alaska Native and Native Hawaiian / Pacific Islander because the results were statistically unstable. Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed April 12, 2019, http://ask.chis.ucla.edu.

CALIFORNIA HEALTH CARE FOUNDATION 13 Health Disparities by Race and Ethnicity Childhood Vaccination Rates, by Race/Ethnicity Prevention California, 2017 In 2017, California’s childhood vaccination rate of 69% was below LET’S GET HEALTHY CALIFORNIA TARGET the Let’s Get Healthy California target 80.0% of 80%. Childhood vaccination rates did not vary much among races/ 67.4% 67.9% 69.7% 68.6% 66.7% ethnicities. Vaccinations help provide immunity against potentially life- threatening diseases.

Latino White Multiracial Asian California

Notes: Coverage among children 19–35 months. Let’s Get Healthy California, which was launched in 2012, aims to achieve the triple aim of better health, better care, and lower costs, with 10-year improvement targets for 39 health care indicators. Source uses Hispanic and Multiple Races. Estimates were not available for Black, American Indian or Alaska Native, and Native Hawaiian or other Pacific Islander. Source: “2017 Childhood Combined 7-Vaccine Series Coverage Dashboard,” Centers for Disease Control and Prevention, last reviewed October 11, 2018, www.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 14 Health Disparities by Race and Ethnicity Adults Age 65+ Who Had Flu Shot, by Race/Ethnicity Prevention California, 2017 About 60% of Californians age 65 and older had a flu shot in the last year. Black seniors had the lowest 64.2% vaccination rate, at 40%. Seniors are 61.6% 59.3% at greater risk of serious complications 52.4% from the flu compared to younger adults because human immune

* 40.3% defenses become weaker with age.

Black Asian White Latino California

Notes: Adults 65 and older who had a flu shot within the past year. Crude prevalence (not age-adjusted). Source uses Hispanic. Prevalence estimates were not available for American * ”People 65 Years and Older & Influenza,” Centers for Indian or Alaskan Native, Native Hawaiian or Other Pacific Islander, Other, and Multiracial. Disease Control and Prevention, last reviewed February 12, Source: “BRFSS Prevalence & Trends Data,” Centers for Disease Control and Prevention, accessed April 12, 2019, www.cdc.gov. 2019, www.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 15 Health Disparities by Race and Ethnicity Cancer Screening Tests, by Race/Ethnicity Prevention California, 2016 Screening offers the ability to detect

Asian Black Latino Multiracial White California cancer early before symptoms appear. With the exception of colorectal Colorectal 71.2% screening, there was not much 76.3% 53.8% variation in rate of cancer screening N/A 78.6% tests among racial/ethnic groups. 71.4% Latinos were less likely to get Mammogram colorectal screening than other races/ 74.3% 77.5% ethnicities. 72.4% 86.6% 76.0% 74.3% Pap Smear 74.1% 80.2% 83.1% N/A 83.7% 81.6%

Notes: Mammogram includes women age 40 and over who had a mammogram in the past two years. Pap smear includes women age 21 to 65 who had a pap test in the past three years. Colorectal includes respondents age 50 to 75 who fully met the US Preventive Service Task Force recommendation. Crude prevalence (not age-adjusted). Source uses Hispanic. Prevalence estimates were not available for American Indian or Alaskan Native, Native Hawaiian or other Pacific Islander, and Other. Source: “BRFSS Prevalence & Trends Data,” Centers for Disease Control and Prevention, accessed April 12, 2019, www.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 16 Health Disparities by Race and Ethnicity Asthma Emergency Department Visits, Children and Quality

Adolescents, by Race/Ethnicity Emergency department (ED) visits for California, 2017 asthma may be avoided with proper RATES PER 10,000 POPULATION asthma management. Black children were much more likely than other 253.7 racial/ethnic groups to visit the ED for asthma. Slightly more than one in four Black children have been diagnosed LET’S GET HEALTHY CALIFORNIA TARGET with asthma, higher than California’s 28.0 overall rate of one in seven children (not shown). 75.5 62.0 74.5 50.2 35.3

Black Latino Native White Asian / Pacific California American Islander

Notes: The number of emergency department visits with asthma as the primary diagnosis among children age 0–17 in California. Records are visit-based and not person-based. Source uses Hispanic, African-American, and American Indian / Alaskan Native. Let’s Get Healthy California, which was launched in 2012, aims to achieve the triple aim of better health, better care, and lower costs, with 10-year improvement targets for 39 health care indicators. Source: “Healthy Beginnings / Reducing Childhood Asthma ED Visits,” Let’s Get Healthy California, accessed April 25, 2019, https://letsgethealthy.ca.gov.

CALIFORNIA HEALTH CARE FOUNDATION 17 Health Disparities by Race and Ethnicity Preventable Hospitalizations, by Race/Ethnicity Quality California, 2015 Potentially preventable

ASIAN / hospitalizations are admissions to a HOSPITAL ADMISSIONS PER 100,000 POPULATION PACIFIC BLACK LATINO WHITE ISLANDER hospital for certain acute illnesses or Angina, adults age 18 and over 9.5 39.3 19.1 12.3 worsening conditions that might not have been required if the conditions Asthma, adults age 18–39 3.2 38.4 7.1 8.9 had been successfully managed

Asthma, children age 2–17 50.3 266.0 80.0 64.3 by primary or preventive care in outpatient settings.* The rates of Chronic obstructive pulmonary disease or asthma, 153.0 683.6 209.2 261.0 adults age 40 and over preventable hospitalizations for Blacks

Congestive heart failure 175.6 708.9 295.1 237.3 were much higher than the rates for other races/ethnicities. Diabetes (long-term complications), adults 45.5 230.1 172.9 75.0

Diabetes (short-term complications), adults 15.4 176.1 58.4 63.2

Diabetes (short-term complications), 6.2 60.8 18.1 31.6 children age 6–17

* Ernest Moy, Eva Chang, and Marguerite Barrett, Note: Source uses Hispanic. “Potentially Preventable Hospitalizations — United States, 2001–2009,” Morbidity and Mortality Weekly Report Source: “National Healthcare Quality and Disparities Reports,” Agency for Healthcare Research and Quality, n.d., https://nhqrnet.ahrq.gov. 62, no. 3 (Nov. 22, 2013): 139–43, www.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 18 Health Disparities by Race and Ethnicity Hospital Readmissions, by Race/Ethnicity Quality California, 2017 Hospital readmissions can be an

LET’S GET HEALTHY CALIFORNIA indicator of poor clinical quality. TARGET 11.9% Steps to reduce hospital readmissions

18.6% CALIFORNIA include better coordination of care and 14.6% 16.4% communications between providers, patients, and their caregivers, and 14.7% 14.1% 14.0% improved discharge planning. In 2017, readmission rates were highest for Blacks.

Black Native Latino Asian / Pacific White American Islander

Notes: Adults age 18 and older. Rates of all-cause, unplanned hospital readmissions within 30 days of discharge. The rate is not risk-adjusted. Source uses Hispanic, African-American, and American Indian / Alaskan Native. Let’s Get Healthy California, which was launched in 2012, aims to achieve the triple aim of better health, better care, and lower costs, with 10-year improvement targets for 39 health care indicators. Source: “Redesigning the Health System / Reducing Hospital Readmissions,” Let’s Get Healthy California, State of California, accessed May 24, 2019, https://letsgethealthy.ca.gov.

CALIFORNIA HEALTH CARE FOUNDATION 19 Health Disparities by Race and Ethnicity Hospital Deaths, by Race/Ethnicity Quality California, 2017 In 2017, nearly one-third of deaths occurred in the hospital. Whites were PERCENTAGE OF DEATHS less likely to die in the hospital than other races/ethnicities. 38.8% CALIFORNIA 37.2% 31.0% 35.0% 34.6%

27.1%

Asian / Pacific Latino Black Native White Islander American

CALIFORNIA HEALTH CARE FOUNDATION 20 Health Disparities by Race and Ethnicity Hospital Deaths, Selected Conditions Quality California, 2015 Compared to other races/ethnicities, DEATHS PER 1,000 HOSPITAL ADMISSIONS Blacks had lower rates of death per hospital admission for acute

CORONARY ARTERY CONGESTIVE HEART ACUTE MYOCARDIAL PNEUMONIA BYPASS GRAFT* FAILURE INFARCTION myocardial infarction and congestive

Asian / Pacific heart failure but a higher death rate 17.7 14.4 41.0 18.8 Islander for coronary artery bypass graft.

Black 19.6 12.1 31.5 16.2

Latino 15.0 13.2 43.9 16.6

White 16.8 17.8 45.4 19.8

California 16.6 15.8 43.5 18.7

*Age 40 and over Note: Source uses Hispanic. Source: “National Healthcare Quality and Disparities Reports,” Agency for Healthcare Research and Quality, n.d., https://nhqrnet.ahrq.gov.

CALIFORNIA HEALTH CARE FOUNDATION 21 Health Disparities by Race and Ethnicity Childhood Overweight, by Race/Ethnicity Chronic Conditions California, 2015 to 2017 Nearly one in five Latino children were overweight for their age. Among 18.7% other things, an unhealthy diet, lack of exercise, and sedentary activities 15.5% 15.3% can impact weight gain. Children who are overweight are more prone to 11.8% becoming overweight adults.*

Latino Black White California

* Frank M. Biro and Michelle Wien, “Childhood Obesity Notes: Overweight for age (does not factor height). Data reflect children under age 12. Source uses African American. Estimates are not shown for Asian, American Indian / Alaska Native, and Adult Morbidities,” The American Journal of Clinical Native Hawaiian / Pacific Islander, and Two or More Races because the results were statistically unstable.. Nutrition: 91, no. 5 (May 2010): 1492S-1505S, doi: 10.3945/ Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed April 12, 2019, http://ask.chis.ucla.edu. ajcn.2010.28701B.

CALIFORNIA HEALTH CARE FOUNDATION 22 Health Disparities by Race and Ethnicity Adolescent Overweight and Obesity, by Race/Ethnicity Chronic Conditions California, 2015 to 2017 More than one-third of California’s adolescents were overweight or obese. One in 4 Latino adolescents Obese Overweight were obese compared to less than 1 in 10 white adolescents. Obesity 24.8% can lead to high blood pressure, high cholesterol, and an increased risk of 18.1% type 2 diabetes.

8.7% 19.0% 16.2% 16.9%

Latino White California

Notes: Data reflect adolescents age 12 to 17. Adolescents with a body mass index (BMI) at or above the 85th percentile based on height and weight were classified as overweight. Adolescents with a BMI at or above the 95th percentile were classified as obese. Estimates are not shown for African American, American Indian / Alaska Native, Native Hawaiian / Pacific Islander, and Two or More Races because the results were statistically unstable. Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed May 28, 2019, http://ask.chis.ucla.edu.

CALIFORNIA HEALTH CARE FOUNDATION 23 Health Disparities by Race and Ethnicity Adults with Chronic Conditions, by Race/Ethnicity Chronic Conditions California, 2017 Asthma In 2017, significant racial and ethnic 11.9% 20.4% disparities existed among prevalence 13.2% rates for chronic conditions. 27.5% 20.0%* 18.1% Diabetes 8.8% 16.4% 12.6% 7.4% Asian 15.9%* 9.0% Black Heart Disease Latino 4.0%* Multiracial 7.1% 4.7% Native American 5.4%* White 14.2%* 9.1% Obesity 11.6% 37.8% 34.4% 1.0%* 34.5% 23.2%

* Statistically unstable. Notes: Source uses African American, American-Indian / Alaska Native, and Two or More Races. Estimates are not shown for Native Hawaiian / Pacific Islander because the results were statistically unstable.. Source: “AskCHIS,” UCLA Center for Health Policy Research, accessed April 12, 2019, http://ask.chis.ucla.edu.

CALIFORNIA HEALTH CARE FOUNDATION 24 Health Disparities by Race and Ethnicity Cancer Incidence Rates, New Cases, by Race/Ethnicity Chronic Conditions

California, 2016 Cancer incidence rates vary by race RATE PER 100,000 POPULATION Breast - Female and type of cancer. White women had 100.8 119.8 the highest rate of new breast cancer 92.8 134.9 cases while Blacks had the highest 118.7 rates of new prostate, colorectal, and Cervical 6.5 lung cases. Latinas had the highest 8.1 9.3 rate of new cervical cancer cases. 6.3 7.2 Asian / Pacific Islander Colorectal 31.0 Black 37.3 Latino 31.3 34.4 White 33.9 Lung California 32.9 47.4 23.1 44.2 38.3 Prostate - Male 48.7 125.4 73.6 86.9 86.0 Notes: Excludes in situ cancers. Source uses Hispanic. Source: Annual Statistical Tables by Site (1998-2016), California Cancer Registry, n.d. www.ccrcal.org.

CALIFORNIA HEALTH CARE FOUNDATION 25 Health Disparities by Race and Ethnicity Cancer Early Diagnosis, by Race/Ethnicity Chronic Conditions California, 2014 Early diagnosis can help save lives by Breast - Female identifying cancers when they require 74.0% 66.5% less-extensive treatment and have 66.0% 72.5% better outcomes. Black females and Cervical Invasive Latinas were less likely to have breast 38.2% 42.3% cancer diagnosed at an early stage 42.5% 43.9% than white and Asian / Pacific Islander Colorectal - Female Asian / Pacific Islander women. The mammography rates for 40.8% 41.3% Black Black females and Latinas were similar 41.4% Latino to the rates for white and Asian 42.6% White Colorectal - Male females (not shown). 42.6% 39.8% 39.8% 42.2% Prostate - Male 70.7% 69.9% 66.2% 71.1%

Note: Source uses Hispanic and African American. Source: California Cancer Facts & Figures 2017, California Cancer Registry, 2017, www.ccrcal.org.

CALIFORNIA HEALTH CARE FOUNDATION 26 Health Disparities by Race and Ethnicity Cancer Deaths, by Condition Chronic Conditions

California, 2016 Blacks had the highest death rates for RATE PER 100,000 POPULATION Breast - Female breast, colorectal, lung, and prostate 12.0 31.7 cancer among all races and ethnicities. 14.8 20.2 18.5 Cervical 2.1 Asian / Pacific Islander 2.5 2.9 Black 1.8 Latino 2.2 Colorectal White 10.3 16.8 California 11.4 12.6 12.2 Lung 23.5 37.1 15.8 32.5 27.9 Prostate - Male 9.6 45.0 17.6 22.1 20.6

Notes: Excludes in situ cancers. Source uses Hispanic. Source: Annual Statistical Tables by Site (1998-2016), California Cancer Registry, n.d. www.ccrcal.org.

CALIFORNIA HEALTH CARE FOUNDATION 27 Health Disparities by Race and Ethnicity Children with Serious Emotional Disturbance, Behavioral Health by Race/Ethnicity Serious emotional disturbance (SED) California, 2014 varied slightly by race/ethnicity:

CALIFORNIA Latino, Black, Native American, and 7.6% 8.1% 8.1% Pacific Islander children experienced 7.9% 7.6% 7.1% 7.0% 6.9% rates of SED close to 8%, while rates for white, Asian, and multiracial children were about 7%.

Latino Black Native Pacific Multiracial Asian White American Islander

Note: Serious emotional disturbance is a categorization for children age 17 and under who currently have, or at any time during the past year have had, a mental, behavioral, or emotional disorder resulting in functional impairment that substantially limits functioning in family, school, or community activities. Source: Charles Holzer and Hoang Nguyen, “Estimation of Need for Mental Health Services”.

CALIFORNIA HEALTH CARE FOUNDATION 28 ACROSS RACIAL/ETHNIC GROUPS, THE SHARE OF STUDENTS WHO REPORTED DEPRESSION-RELATED FEELINGS

Health Disparities by Race and Ethnicity Children with Depression-Related Feelings, by Race/Ethnicity Behavioral Health California, 2015 to 2017 Across racial/ethnic groups, the share Asian 21.2% of students who reported depression- 24.0% 31.3% related feelings increased between the Black 28.4% Grade 7 24.9% 7th grade and the 11th grade. Native 29.3% Grade 9 Latino American and Pacific Islander children 26.9% Grade 11 31.3% in grade 11 reported depression- 32.7% Multiracial related feelings at the highest rates. 27.7% 32.5% 33.4% Native American 25.5% 32.6% 38.4% Pacific Islander 25.5% 32.6% 38.4% White 19.1% 28.7% 31.2% California 24.2% 29.6% 32.3%

Notes: Percentage of students who answered “yes” to the question: “During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more that you stopped doing some usual activities? ”Source uses Hispanic or Latino, Black or African American, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, and Mixed. Source: Gregory Austin et al., School Climate, Substance Use, and Well-Being Among California Students, 2015-2017: Results of the Sixteenth Biennial Statewide Student Survey, Grades 7, 9, and 11, WestEd, 2018, https://data.calschls.org (PDF).

CALIFORNIA HEALTH CARE FOUNDATION 29 Health Disparities by Race and Ethnicity Depression Prevalence, by Race/Ethnicity Behavioral Health California, 2017 Depression prevalence among adults varied across races and ethnicities. About one in five multiracial, Black, 23.3% Native American, and white adults 21.5% 21.1% reported depression compared to CALIFORNIA 19.1% 17.3% about one in eight Asian adults.

14.3% 11.8%

Multiracial Black White Native Latino Asian American

Notes: Adults who have ever been told they have a form of depression. Crude prevalence (not age-adjusted). Source uses Hispanic and American Indian or Alaskan Native. Prevalence estimates are not available for Native Hawaiian or other Pacific Islander. Source: “BRFSS Prevalence & Trends Data,” Centers for Disease Control and Prevention, n.d. www.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 30 Health Disparities by Race and Ethnicity Suicide Rates, by Race/Ethnicity Behavioral Health California, 2017 In 2017, whites accounted for more RATE PER 100,000 POPULATION than 60% of the 4,300 suicides in California. While suicides among 20.2 18.6 Native Americans represented only 1% of total suicides, the suicide rate for Native Americans was higher than all other races/ethnicities and almost double the state average. 10.9 8.0 7.6 5.7

Native White Black Asian / Pacific Latino California American Islander NUMBER OF DEATHS

34 2,783 181 417 897 4,312

Note: White includes Other and Unknown. Source uses Hispanic and American Indian. Source: “Overall Injury Surveillance,” California Dept. of Public Health, accessed April 11, 2019, http://epicenter.cdph.ca.gov.

CALIFORNIA HEALTH CARE FOUNDATION 31 Health Disparities by Race and Ethnicity Opioid Overdose Emergency Department Visits, Behavioral Health by Race/Ethnicity While white people accounted for California, 2017 63% of the 4,281 nonfatal opioid AGE-ADJUSTED RATE PER 100,000 POPULATION overdose emergency department 16.5 16.3 16.1 visits, the rate of such visits for whites was similar to the rates for Blacks and Native Americans.

10.3

6.8

1.9

White Black Native American Latino Asian California

NUMBER OF NONFATAL OPIOID OVERDOSE ED VISITS

2,684 424 38 1,016 119 4,281

Note: Emergency department (ED) visits caused by nonfatal acute poisonings due to the effects of all opioid drugs, excluding heroin, regardless of intent (e.g., suicide, unintentional, or undetermined). Source: “California Opioid Overdose Surveillance Dashboard,” California Dept. of Public Health, accessed April 12, 2019, https://discovery.cdph.ca.gov.

CALIFORNIA HEALTH CARE FOUNDATION 32 Health Disparities by Race and Ethnicity Drug-Induced Deaths, by Race/Ethnicity Behavioral Health California, 2017 Drug-induced death rates differed AGE-ADJUSTED RATE PER 100,000 POPULATION considerably by race / ethnicity. Native Americans had the highest rate of 32.7 per 100,000 population, 32.7 nearly ten times that of Asian / Pacific Islanders.

19.4 19.4

12.7 7.9 3.4 Native White Black Latino Asian / Pacific California American Islander NUMBER OF DEATHS

71 3,292 512 1,151 224 5,302

Notes: Data come from registered death certificates. Deaths for persons of unknown age are included in the number but not age-adjusted rate. Drug-induced deaths are those with ICD-10 codes that cover unintentional, suicide, homicide, and undetermined poisoning. Source uses Hispanic or Latino, American Indian or Alaska Native, and Black or African American. Source: “Underlying Cause of Death 1999 –2017,” Centers for Disease Control and Prevention, released December 2017, accessed October 18, 2019, https://wonder.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 33 Health Disparities by Race and Ethnicity Opioid Overdose Deaths, by Race/Ethnicity Behavioral Health California, 2017 Nearly 2,200 Californians died from an AGE-ADJUSTED RATE PER 100,000 POPULATION opioid overdose in 2017, with whites representing two-thirds of those 17.6 deaths. Native Americans had the highest opioid overdose mortality rate.

8.9

5.8 5.2 3.1 1.0

Native White Black Latino Asian California American NUMBER OF DEATHS

37 1,460 152 482 65 2,197

Notes: Acute poisoning deaths involving opioids such as prescription opioid pain relievers (e.g., hydrocodone, oxycodone, and morphine), heroin, and opium. Excludes deaths related to chronic use of drugs. Source: “California Opioid Overdose Surveillance Dashboard,” California Dept. of Public Health, accessed April 12, 2019, https://discovery.cdph.ca.gov.

CALIFORNIA HEALTH CARE FOUNDATION 34 Health Disparities by Race and Ethnicity Prenatal Care, First Trimester, by Race/Ethnicity Maternal/Childbirth California, 2017 Prenatal care is an important part of PERCENTAGE OF BIRTHS staying healthy during pregnancy.

CALIFORNIA In 2017, Native Americans were less 84.2% likely than other races to start prenatal 77.9% 87.5% 87.9% HEALTHY PEOPLE 84.2% care in the first trimester. 2020 TARGET 78.7% 81.7% 68.5%

Native American Black Latina Multiracial Asian White

Notes: Percentage of live births where mother began prenatal care in the first trimester. Source uses Hispanic or Latino, Black or African American, American Indian or Alaska Native, and More than one race. Native Hawaiian or Other Pacific Islander (71.2%) not shown. The US government’s Healthy People 2020 program establishes science-based 10-year national objectives for improving the health of all Americans, www.healthypeople.gov. Source: Author calculations based on “Natality 2007-2017,” CDC WONDER Online Database, Centers for Disease Control and Prevention, October 2018, https://wonder.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 35 Health Disparities by Race and Ethnicity Low-Risk, First-Birth Cesarean Rate, by Race/Ethnicity Maternal/Childbirth California, 2017 In 2017, nearly one in four births PERCENTAGE OF BIRTHS among low-risk, first-birth Californians were cesarean delivery 29.8% (c-section). The rates for Blacks and CALIFORNIA 24.5% Asians was above the Healthy People 25.6% HEALTHY PEOPLE 2020 TARGET 2020 target of 23.9%. While critical in 23.8% 23.8% 23.9% certain circumstances, c-sections can pose serious risks for both baby and the person giving birth.*

Black Asian / Pacific Latina White Islander

Notes: Low-risk, first-birth cesarean rate represents the percentage of cesarean deliveries among first-time mothers delivering a single baby in a head-down position after 37 weeks gestational age. The technical term for this measure is the nulliparous, term, singleton, vertex (NTSV) cesarean birth rate. The US government’s Healthy People 2020 program establishes science-based 10-year national objectives for improving the health of all Americans, www.healthypeople.gov. * ”Having a C-Section”, March of Dimes, last reviewed Source: Special data request to the California Maternal Quality Care Collaborative, received November 9, 2018. October 2018, www.marchofdimes.org.

CALIFORNIA HEALTH CARE FOUNDATION 36 Health Disparities by Race and Ethnicity Preterm Births, by Race/Ethnicity Maternal/Childbirth California, 2017 Babies born preterm have higher PERCENTAGE OF BIRTHS rates of death and disability. The rate of preterm births among Blacks was

HEALTHY PEOPLE 67% higher than the rate of preterm 12.6% 2020 TARGET 9.4% births among whites and was above 10.9% the Healthy People 2020 target of CALIFORNIA 9.0% 9.0% 8.7% 9.4%. 7.9% 7.5%

Black Native Latina Multiracial Asian White American

Notes: Percentage of births with less than 37 completed weeks of gestation based on the obstetric estimate. Source uses Hispanic or Latino, Black or African American, American Indian or Alaska Native and More than one race. Native Hawaiian or Other Pacific Islander (9.0%) not shown. The US government’s Healthy People 2020 program establishes science-based 10-year national objectives for improving the health of all Americans, www.healthypeople.gov. Sources: Author calculations based on “Natality 2007-2017,” CDC WONDER Online Database, Centers for Disease Control and Prevention (CDC), October 2018, https://wonder.cdc.gov; and “Preterm Birth,” CDC, www.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 37 Health Disparities by Race and Ethnicity Low Birthweight Births, by Race/Ethnicity Maternal/Childbirth California, 2017 In 2017, one in eight Black babies PERCENTAGE OF BIRTHS had a low birthweight. Having a low birthweight can cause serious 12.2% health problems for some babies.

HEALTHY PEOPLE These babies may have trouble eating, 2020 TARGET 7.8% gaining weight, and fighting off

8.4% CALIFORNIA infections. Some low-birthweight 6.9% 7.7% 7.5% babies may also have long-term

6.6% * 5.7% health problems.

Black Native American Multiracial Asian Latina White

Notes: Percentage of births where infant weighed less than 2,500 grams. Source uses Hispanic or Latino, Black or African American, American Indian or Alaska Native, and More than one race. Native Hawaiian or Other Pacific Islander (6.7%) not shown. The US government’s Healthy People 2020 program establishes science-based 10-year national objectives for improving the health of all Americans, www.healthypeople.gov. * “Low Birthweight,” March of Dimes, last reviewed March Source: Author calculations based on “Natality 2007-2017,” CDC WONDER Online Database, Centers for Disease Control and Prevention, October 2018, https://wonder.cdc.gov. 2018, www.marchofdimes.org.

CALIFORNIA HEALTH CARE FOUNDATION 38 Health Disparities by Race and Ethnicity Infant Mortality, by Mother’s Race/Ethnicity Maternal/Childbirth California, 2016 The infant mortality rate for Blacks RATE PER 1,000 LIVE BIRTHS was more than twice the rate for whites and Asians. 8.2 HEALTHY PEOPLE 2020 TARGET 6.0 UNITED STATES 5.8 5.3* CALIFORNIA 4.3 4.2 3.5 3.1

Black Native Latina White Asian American

*Unreliable — fewer than 20 deaths in the numerator. Note: Infant mortality is the death of an infant before his or her first birthday. Source uses Hispanic or Latino, Black or African American, and American Indian or Alaska Native. The US government’s Healthy People 2020 program establishes science-based 10-year national objectives for improving the health of all Americans, www.healthypeople.gov. Source: “Linked Birth / Infant Death Records 2007-2016,” CDC WONDER Online Database, Centers for Disease Control and Prevention, n.d., https://wonder.cdc.gov.

CALIFORNIA HEALTH CARE FOUNDATION 39 Health Disparities by Race and Ethnicity Maternal Mortality, by Race/Ethnicity Maternal/Childbirth California, 2000 to 2013 Throughout the 21st century, there MATERNAL DEATHS PER 100,000 LIVE BIRTHS have been significant racial disparities Black Latina Asian / Pacific Islander White in the maternal mortality rate in

51.0 California. During this period, Black

45.7 46.1 women’s maternal mortality rates

41.5 41.1 were as much as four times higher 37.2 than white women’s. Recent studies 35.3 33.8 32.2 have shown that Black women 29.0 29.5 26.4 continue to have significantly higher maternal mortality rates even when age, education, and insurance

10.9 12.2 11.5 12.4 * 11.8 12.8 10.9 10.7 coverage are considered. 9.5 10.9 10.8 11.7 11.9 11.7 9.5 9.2 10.6 11.1 10.4 8.1 8.9 7.8 9.8 10.2 9.6 8.5 9.0 9.2 9.3 8.4 7.9 7.1 5.6 7.0 6.9 4.9 2000-2 2001-3 2002-4 2003-5 2004-6 2005-7 2006-8 2007-9 2008-10 2009-11 2010-12 2011-13

Note: Maternal mortality refers to deaths 42 days or less postpartum. Three-year moving average is used. * “Birth Equity,” California Maternal Quality Care Source: The California Pregnancy-Associated Mortality Review: Report from 2002 to 2007 Maternal Death Reviews, California Dept. of Public Health, Spring 2018, https://www.cdph.ca.gov (PDF). Collaborative, accessed July 15, 2019, www.cmqcc.org.

CALIFORNIA HEALTH CARE FOUNDATION 40 Health Disparities by Race and Ethnicity Prenatal and Postpartum Depressive Symptoms, Maternal/Childbirth by Race/Ethnicity Black and Latina mothers were more California, 2013 to 2015 likely to report having prenatal and Prenatal Postpartum postpartum depressive symptoms than white and Asian mothers. 19.9% Emotional well-being during and after pregnancy is central to 17.1% women’s health, and to their infants’ 15.6% 15.4% development.* 14.1% 13.5% 11.7% 10.9% 10.3% 9.5%

Black Latina Asian / Pacific White California Islander Note: Experienced both of the following for two weeks or longer: felt sad, empty, or depressed for most of the day; lost interest in most things she usually enjoyed. Prenatal depressive symptoms are during pregnancy. Postpartum depressive symptoms are since most recent birth. Source uses Hispanic. Source: MIHA Data Snapshot, by Race/Ethnicity, 2013-2015, California Dept. of Public Health, 2018, https://www.cdph.ca.gov/Programs/CFH/DMCAH/MIHA/CDPH%20Document%20 * ”Depression During Pregnancy,” March of Dimes, Library/2013-2015/Snapshot_ByRaceEthnicity_2013-2015.pdf (PDF). last reviewed March 2019, www.marchofdimes.org.

CALIFORNIA HEALTH CARE FOUNDATION 41 Health Disparities by Race and Ethnicity

ABOUT THIS SERIES The California Health Care Almanac is an online clearinghouse for data and analysis examining the state’s health care system. It focuses on issues of quality, affordability, insurance coverage and the uninsured, and the financial health of the system with the goal of supporting thoughtful planning and effective decisionmaking. Learn more at www.chcf.org/almanac.

AUTHOR Robbin Gaines, MBA, is a senior program officer with CHCF’s Market Analysis and Insight team, which promotes greater transparency and accountability in California’s health care system.

ACKNOWLEDGMENT Jen Joynt, independent health care consultant

FOR MORE INFORMATION

California Health Care Foundation

1438 Webster Street, Suite 400

Oakland, CA 94612

510.238.1040

www.chcf.org

CALIFORNIA HEALTH CARE FOUNDATION 42